imaging in cancer therapeutics 2015

Imaging in Cancer Therapeutics!Past, Present and Future!

Parminder S. Basran, PhD, FCCPMSenior Medical PhysicistBCCA- Vancouver Island CentreAdjunct Associate ProfessorUniversity of Victoria- Dept. Physics & Astronomy

@psbasranwww.slideshare.net/psbasran!

Outline!

•  Introduction: What is Cancer?!

• Clinical Example: Lung cancer!

• Challenges!

• Conclusions / Future Directions!

Introduction: Cancer!

http://en.wikipedia.org/wiki/Cancer!

“a class of diseases in which a group of cells display uncontrolled growth, invasion that intrudes upon and destroys adjacent tissues, and sometimes metastasis, or spreading to other locations in the body via lymph or blood.”!

How do you detect cancer?!

Detection & Screening!• Not only is imaging used to measure the

extent of the disease, it is commonly used to screen patients (generally higher risk patients) to mitigate morbidity from cancer. !

• Breast Cancer / Mammography!

• Colorectal Cancer / CT Colonoscopy (iScanImaging. “3D Virtual Colonoscopy." Online video clip. YouTube. YouTube, 18 Apr. 2012. Accessed May 20, 2015)!

Individualized Cancer Care!

• As our understanding of cancer increases, so does the recognition that each tumor is unique.!

• In the last decade, the focus in cancer research on the genetic make-up of cancer!

• Now it is clear that the tumor microenvironment, cellular and protein interactions affect disease progression, aggressiveness and response to treatment.!

Individualized Cancer Care!

Subsequently, imaging the !• tumor micro-environment!• host/stem cell interactions,!• various proteins !

can be used to assess !• disease progression!• aggressiveness !• response to treatment!

Evolution of Imaging Technologies!

Example: Lung Cancer!

•  Illustrative example on the role of imaging in cancer management!

Patient Consult!• 70 year old male!• Smoker for 20 years, quit 2 years ago!• Painter!• History of cancer in family!

• Father had prostate cancer!• Uncle had lung cancer!

Symptoms!• Coughing starting about 3 years ago, persistent for 2 years but got worse over last year!

• Dull chest pain over the last year!• Wheezy/hoarsness in breathing !• Weight loss over the last year!

Diagnosis!

Tests that may be performed include:!

•  Chest x-ray!•  Sputum cytology test to look for cancer cells!•  Blood work!

Staging!

!!!!!

Staging!Stage 0 - the cancer has not spread beyond the inner lining of the lung!

Stage I - the cancer is small and hasn't spread to the lymph nodes!

Stage II - the cancer has spread to some lymph nodes near the original tumor!

Stage III - the cancer has spread to nearby tissue or spread to far away lymph nodes !

Stage IV - the cancer has spread to other organs of the body such as the other lung, brain, or liver!

!

Staging!Stage 0 - the cancer has not spread beyond the inner lining of the lung!

Stage I - the cancer is small and hasn't spread to the lymph nodes!

Stage II - the cancer has spread to some lymph nodes near the original tumor!

Stage III - the cancer has spread to nearby tissue or spread to far away lymph nodes !

Stage IV - the cancer has spread to other organs of the body such as the other lung, brain, or liver!

!

Prognosis!

Stage! Survival rate after 5 years!

Treatment!

0 / 1! 80%! Surgery (segmentectomy/wedge resection), photodynamic therapy, cryotherapy, radiation therapy!

2! 40-50%! Lobectomy; pneumonectomy; or segmental, wedge !Radiation therapy, Adjuvant chemotherapy (Cisplatin) after curative surgery. !

3! 10-23 %! Chemo-radiation therapy for patients with stage IIIA-N2 disease.!Radiation therapy alone for patients medically unfit!

4! <10%! Chemotherapy, Radiation for palliative/symptom relief!

Treatment Strategy!

Radiation Therapy!•  Deliver high dose (60 Gy) with multiple

photon beams (6 MeV range)!•  Need to simulate the treatment virtually!•  Obtain a CT scan to define the tumor and

normal tissues!•  Simulate the radiation beams in the CT

dataset!

Radiation Therapy!

Radiation Therapy: CT imaging!

PET-CT!

Positron Emission Tomography (PET), is a non-invasive molecular imaging technique that uses various radio-labeled compounds and visualizes metabolic differences between tissues, thus depicting the functional status of a suspicious lesion. !

PET-CT in RT!

PET-CT in RT!

PET-CT in RT: other consequences!

Other hybridized imaging in RT!

PET = Tumor metabolism!

SPECT := Single Photon Emission Computed Tomography!

-  Tc-99m !

SPECT – CT !

SPECT-CT imaging system!

Single slice low dose CT imaging system!

Dual head gamma camera system !

SPECT-CT in RT!

Both anatomical and functional information together is more insightful that each independently assessed.!

Sparing functional lung tissue in radiation therapy!

GTV

CTV

ITV!!!!

PTV!

If you can’t see it…!

4D CT!

Challenges!

Clinical effectiveness, quality of life and costs!

Has changed the practice of management.!But challenges remain:!

Challenges: How much?!

Tools (WHAT)!•  A better mouse-trap!•  Efficiency vs. efficacy!•  Risks!•  $!

!Techniques (HOW)!

•  When you have a hammer …!•  Diagnosis, Prognosis, Follow-up!•  Clinical Indications!•  Clinical Adoption!!

Semantics in a Multi-disciplinary world!!

!

Challenges in Cancer Management!

Challenges: Example!Tools (WHAT = DEFORMABLE REGISTRAION) !

•  A better mouse-trap : A vendor’s black-box algorithm!

•  Efficiency vs. efficacy !•  Risks : !•  $!

!Techniques (HOW = USE OF DR in Radiation

Oncology)!•  Diagnosis, Prognosis, Follow-up!•  Clinical Adoption : is there a clinical impact?!

!!

Challenges: DR in RT!

Day !1!

Day !2!

Day !3!

T1 T2

Example: Quantifying the Accuracy of Deformable Registration!

CATPHAN 600 Phantom Reference CT!•  Scanned at high resolution!•  CT image quality phantom!•  Various testing disks!

Matlab !•  Deformed datasets (CT)!!GE Workstation!•  Deformed CT=> Ref CT!•  Registered CT!!Matlab!•  Quantitatively examine Reg CT !•  Compare with Ref CT !

!Deformed in Y and Z (2cm)

!

Deformation ranged from 1 – 3 cm! dY = couch change! (curved to flat)! dX = curved spine! (scoliosis)! dZ = curved neck! (chin up/down)!Combined deformations!

Example: Quantifying the Accuracy of Deformable Registration!

Results – Ref (1)!

Results – Def (2)!

Results – Reg (3)!

If using deformable registration with GE, consider!!1)  Contouring errors of at least few mm!!2)  Image quality is largely retained!

-  So suspicious high / low contrast objects are likely correlated!

3)  Patient rotations will cause headaches!-  Especially yaw rotations!!!

Example: Quantifying the accuracy of Deformable Registration!

Example: Quantifying the Accuracy of Deformable Registration (CT-CT)!

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Original CT Dataset!!!!

Example: Quantifying the accuracy of Deformable Registration (CT-CT)!

!!

Deformed CT Dataset!!!!

Example: Quantifying the accuracy of Deformable Registration (PET-PET)!

!!

Original PET Dataset!!!!

Example: Quantifying the accuracy of Deformable Registration (PET-PET)!

!!

Deformed PET Dataset!!!!

Conclusions / Future Considerations!

Bold Prediction (2012)!

Multi-modality imaging will replace ‘gold standard’ !

• PET-CT is now standard of care for Lung, HN, Cervical and other cancers (limited only by availability)!

• MR-PET is now a commercially available product!

PET-MR!Siemens: mMR!See http://www.healthcare.siemens.com/magnetic-resonance-imaging/mr-pet-scanner/biograph-mmr!

GE: Signa Pet MR !(GE Healthcare, “PET/MR Design” Online video clip. YouTube. YouTube, 12 Nov. 2014. Accessed May 20, 2015)!see http://www3.gehealthcare.com/en/products/categories/magnetic_resonance_imaging/signa_pet-mr !

Merging of Diagnostics + Therapeutics!- MRI+ treatment delivery systems!

- Co-60+MR !(UW Health, “MRI-Guided Radiation Therapy” Online video clip. YouTube. YouTube, 13 Feb. 2015. Accessed May 20, 2015)!!- Protons + MR !- (job add: http://www.radiotherapie.nl/research/jobs/feasibility-of-a-mri-guided-proton-radiotherapy )!

!!Big (Imaging) Data (at 44s)!(Cisco, “The Big Data Opportunity in Medicine” Online video clip. YouTube. YouTube, 16 Oct. 2014. Accessed May 20, 2015)!

! Relational !Data Processing!

…!!

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Thank You / Questions!

pbasran@bccancer.bc.ca / @psbasran!

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